Healthcare Provider Details

I. General information

NPI: 1063606242
Provider Name (Legal Business Name): DERMATOLOGY MEDICAL GROUP OF OXNARD AND CAMARILLO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 05/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PASEO CAMARILLO SUITE 104
CAMARILLO CA
93010-5900
US

IV. Provider business mailing address

500 PASEO CAMARILLO SUITE 104
CAMARILLO CA
93010-5900
US

V. Phone/Fax

Practice location:
  • Phone: 805-482-4646
  • Fax: 805-987-2533
Mailing address:
  • Phone: 805-482-4646
  • Fax: 805-987-2533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberA75621
License Number StateCA

VIII. Authorized Official

Name: DR. JACOB E. LAU
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 805-482-4646